Nuclear Cardiac

1.

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Adequacy of Exercise
a.
Double product (DP) = SBP x HR
b.
DP>20,000(25,000 Mettler) = Good wxercise
c.
Stress DP = 2-3x Rest DP
Vasodialators
a.
When >50% stenosis will not dialate
b.
Dyprimamidole/adenosine contra in bronchospasm
Radiotracers
a.
Thallium 201 electron capture
i. Analog of K+ ion pumped into cell via
Na/K pump
ii. Long half-life (73hrs), Poor penetrating
photons (69 83 keV Gamma rays), High
absorbed dose (0.24rad/mCi)
iii. Images obtained quickly after administration
1.
some say to wait 5-10min to
limit upward creep of the heart
as pts recover lungs decrease
volume and heart slowly creeps
up which may give appearance of
ischemia
iv. High blood pool activity slowly
redistributes into the myocardial ischemic
tissue therefore scan quick
v. High lung activity after exercise or
poststress dilation of the heart indicate
failure
b.
Technicium-99m Sestamibi
i. 15-20mCi
ii. Taken up by diffusion and bound by
myocyte mitochondria
iii. No significant redistribution effect and
washout is negliable gets stuck in the cells
iv. One day 8-12mCi for rest and 4hrs later 3x
for stress
v. Wait 30-60min after stress to allow for
biliary (give PO) and background clearance.
c.
Technicium 99m Tetrofosmin (8-25mCi)
i. Goes into myocardium faster than Sestamibi
and clears for background faster allowing
quicker imaging
d.
Dual-Isotope
i. Thallium for rest first and then Tc-99 for
stress
ii. Energy and photon flux of Tc is higher
therefore no problem
e.
Gated SPECT
i. Best will normal rate/rhythem
ii. Arrhythmias problems for gating
iii. Stroke volume doughnuts if broken
akinesis vs aneurysm check paradox
(intense signal =aneurysm)
Pharcological Stress
a.
Dipyridmidole inhibits adenosine deaminase
i. Hold theophyline
ii. Aminophyline 75mg if symptomatic
b.
Adenosine
i. Shorter life than dipyridmidole
ii. Not for asthma, copd and av-blocks
Interpretation
a.
Check Bowel activity
i. Stress activity less than rest due to
splanchnic vasoconstriction
ii. Activity can mask or create defects
b.
Check all contours to ensure accuracy
c.
Check lung to heart ration >60-65% is abnormal
d.
Reversibly Ischemic
i. Inadequately perfused at exercise
e.
Fixed Defect
i. Attenuation artifact? breast or diaphragm
ii. Infarct, stunned, ischemia-stunned,
hibernating (FDG/delayed T1-201)
f.
Peri-infarct Ischemia

g.
h.

i.

j.

k.

l.

m.

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7.

n.
o.
p.
Specific
PET
a.
b.
c.

i. Ischemic tissue adjacent to infracted area

ii. May be STUNNED
Capillary disease in DM, LBBB, vasospasm, vasculitis shows
signs of ischemia with normal arteries
Hibernating Myocardium
i. VERY ISCHEMIC TISSUE
ii. Appears to be infracted but delayed images show
some viability (hibernating)
iii. Will not contract or contracts minimally
iv. FDG/T1-201
v. Dobutamine will show incr. in EF by 5%
Myocardial Infarction
i. Decrease radiotracer on stress and rest
ii. False positive from breast tissue, tables and
subdiaphragmatic structures
1.
reduce artifacts prone position,
gating acquisition, emission with
transmission scanning
Stunned Myocardium
i. Acute infarcts are larger than old infarcts with T1201
1.
cells around infracted tissue are
stunned hypokinetic or akinetic not
holding t1-201
2.
several weeks to become normal
Ischemia-stunned myocardium
i. Due to stress Tc-99m does not enter
ii. Check on scans if the tissue THICKENS if it
thickens = stunned; if not =infarct
Infarct-Avid Scans
i. Acute infarct can be detected with Tc-99m
pyrophosphate labeling.
ii. Calcium released from myocytes form
calcification Hot Spot
iii. Antimyosin Antibodies labeled with Tc-99
MUST KNOW
i. TID transient ischemic Dilation
ii. EF <45% or ESV >70mL = higher mortality
iii. CABG 50% restenose after 10 yrs
1.
Septal dyskinesia with preservation of
wall thickening
iv. PTCA 10-25% @ 6 months
1.
patients show transient decrease in
coronary reserve therefore wait 4-8wks
to scan patient
v. LBBB
1.
LV contracts differently on stress
reversible defect on septum - FP
Summed Stress Score (4-8, 9-13, >13)
Summed Rest Score
Summed Difference Score
Perfusion Rubidium or Ammonia
Viability or Hibernating myocardium FDG
Interpretation
i. Reversible viable
ii. Fixed infracted/hibernating
iii. Hibernating myocardium will have normal or
increase FDG uptake
1.
infarct no FDG uptake
2.
Delayed T1-201 scans